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Serial Notching of the Platysma Bands

Ziya Saylan, MD

The platysma bands are visible in older and in younger patients after submental liposuction or patients with an aged neck. The traditional midline suturing was not that satisfactory and with our patients a revision and scar correction in 14% of the cases were necessary. Most of the patients were claiming about a persisting hardened tissue at submental region after the platysmaplasty. Also a Necksling described by Giampappa¹ was to complicated and was not approved by all patients. Until now the surgeons has being doing a lower face-lift or liposuctioning the neck, by combining the procedure with platysmal duplication or suture. Both resulting with terrible scaring.

The midline approach in reduction of the platysma bands can lead to complications including infections, scar formation, hardening, hematoma and a temporary "leather neck" appearance. If a lateral approach is preferred such as posterior neck lift, S-Lift or face lift, the bands may be persistent after the surgery and should be treated separately. With older patients a serial notching with or without a neck lift can be satisfactory.

This procedure is performed in local anesthesia and after marking and infiltration with lidocaine 1% with Adrenalin (Astra Chemicals) multiple small skin incisions are made on the bands and they will be incised at many places individually.

For almost 2 years over 51 patients have been treated with the serial notching of the platysma bands as an adjuvant surgery or as an isolated treatment (23% of the cases underwent only a serial notching of the bands). This study shows that this technique of correction of the platysma bands in older patients and also in some of the younger patients in combination with face or S-Lift or posterior neck lift is more effective and causes less complications than suturing the muscle in the midline.

Platysma bands are classified into 4 types according to their appearance and treatment²:

Type I :
Bands are barely visible in the neck and are handled without midline work.
Type II:
Moderately visible and need only midline suturing of the platysma muscle.
Type III:
Visible bands only with forced contraction that require resection of redundant edges of the muscle and midline suturing.
Type IV:
Dominant visible bands without any forced contraction, need a lateral pull as well as midline work

In April 1999 during a scientific meeting in Berlin, Dr. Robert Ersek³ mentioned for the first time the cutting of the platsymal bands after a submental liposuction because very often they become quite visible especially after submental liposuctions. After using this technique several times for postliposuction cases, I have decided to introduce this method also as an single or adjuvant technique to my neck patients. The neck is neglected by many of the surgeons which should be treated as seriously and effectively as the face.

Indications: We have called this operation as a "Serial Notching of the Platysmal Bands" assisted with a lower facelift, necklift and a submantal liposuction. This method will avoid a facelift in early ages, if the patient claims mostly about the platysma bands. Also at very old patients (Type IV Facelift Patient after the classification of Baker4 ) this procedure will make a facelift unnecessary and it is also an alternative to the patients who reject a major surgery. These are in our opinion the most important indications. The Patients can cover their necks and take place at their social acticities at the following day to surgery. After 5 to 7 days the patients could start working again, this quick recovery was another big advantage of this technique.

Technique:

The patients here show platysma bands so that a marking can be made with a distance of 3-4 cm between every incision (Figure 2).

After washing the skin with Betadine the local anesthesia is injected. If a liposuction is planned an additional infiltration with a classical tumescent solution is necessary. After applying local anaesthesia (1% Lidocain with 1:10000 Adrenalin, Astra chemicals) 1 cc to each site of incision an incision of 1-1.5 cm is made with a Nr. 15 Blade horizontal to the platysma band. With a baby mosquito clamp the muscle band is dissected on both sides so that it can be undermined with the same mosquito clamp and can be taken out of the wound with the help of the instrument. The notching is done with an electrocauthery and repeated many times along the muscle. A skin closure is not always necessary. I prefer a skin glue and steristrip adaptation of the skin for 3-4 days. If a skin laxity of a severe degree is present suturing is advisable. No dressing is required. We close the wounds with sterile pflasters. After 5-6 days only a redness of the skin is left and by even a provocation, the platysma bands are not visible any more. We have observed up to now no scarring, only one case of a small hematoma (no treatment was required), no leather neck cases and no infections. The older patients were particularly satisfied with the results.

The male patient are more advantaged during this surgery, because the skin of the neck at the male population is more thick and elastic because of the beard follicle. As you can see in this case, submantal liposuction and cutting the platysmal bands alone can give satisfactory results.

Advantages:
The most common advantages of this technique are:
1- Ouick recovery of 5-7 days compared with a neck or lower facelift (14 to 21 days).
2- Less possibility of hematoma.
3- No large submental incisions for platysma band plication are necessary.
4- Excellent option for the male Patient who wants a clean neck and jaw contour without a lower facelift ( V.C. Giampapa and B.E. Bernardo1 ).
5- A good alternative to secondary rhytidectomies for treating only the platysma bands.
6- Costs very less than a neck or a lower facelift.
7- Can be performed in local anesthesia.
8- The duration of the surgery is not longer than 20 minutes..
9- The technique can be also easily combined with the lower facelift and necklift techniques.

The disadvantages:
1- Possibility of a visible scar tissue at the anterior neck.
2- If less incisions are made the volume of the retracted muscle between two incisons can be palbable under the skin as a tumor.
3- Does not effect the skin laxity.
4- A dent at the site of incison is also possible if very hypertrophic muscle volumes are cut.

Local anesthesia of the incision sites are done with Lidocaine %1 with Adrenalin (Astra Chemicals). The Lidocaine is proved to be bacteriostatic which assures us a additive security for the surgery. Meanwhile it is to mention that we do use prophylactic antibiotics during this procedure only because of forensic reasons. If a liposuction is planned an additional infiltration with a classical tumescent solution is necessary.

Results:
We applied serial notching of the platysma bands between 1999 and 2001 to 51 patients. 5 males (9 %) and 46 females (91%). The average age was 61. Only one infection (% 2) has been observed where the patient had a diabetes and came to surgery with a good regulated blood sugar which couraged us to apply the surgey. If sutured we have taken the sutures out 6 days after the surgery. Without suturing (Skin glue and Steristips) we have achieved much better results if the skin laxity was optimal.

All the other 50 cases were satisfactory (98%). As mentioned, in 36 cases (72%) we have applied S-Lift5 or a facelift and observed better results. In most of the cases (81%, 40 cases) a submental liposuction was necessary.

Conclusion: This technique alone or combined with the liposuction of the neck and lower facelift such as S-Lift eliminiates the platysma bands especially in older patuíents. Since we use this technique we do not require to perform platysma duplication or suturing. This kind of notching of the platysma bands is mainly done with liposuction. No special and expensive instruments are required, the recovery time is very short, minimal scars are caused and after few days the sutures can be taken away. If multiple and serial imcisions and notching is done no dents and retracted meucles will be palpable or visible. It causes no major swelling and bruising of the neck. Also we have observed only one case of infection and no cases of any other complications. This technique is in our opinion a very good adjuvant to a neck or lower facelift in older patients and in some younger patients (Baker Type II and III).

References:
1. Giampappa, Vincent C., Di Bernardo, Barry E.; Neck Recountouring with Suture Suspension and Liposuction: An Alternative for Early Rhytidectomy Candidate; Aesth. Plast. Surg. 19:217-223, 1995
2. McKinney Peter (Chicago); The Management of Platysma bands; Plast Reconstr Surg 98:999-1006, 1996,
3. Ersek Robert; Personal Communication, May 2000, London Meeting of the EACS.
4. Baker, Daniel; Minimal Incision Rhytidectomy (Short Scar Face Lift) with Lateral SMASectomy: Evolution and Application, Aesth Surg J, 2001; 21:1, Pages 14-26
5. Knipper P, Mitz V, MaladryD et al (Hópital Bouccicaut, Paris) ; Is it necessary to Suture the Platysma muscle on the Midline to Improve the Cervical Profile ? An Anatomic Study Using 20 Cadavres. Ann Plast Surg 39:566-572, 1997
6. Saylan Z., The S-Lift. Less is More; Aesth Surg Journal, 1999; 19:406-409